Another case: Stop endo consults and just do the implant?

Since this is 12 years old I would extract graft and place implant. The average lifespan of a root canal is 10-15 years. This would be a good time to replace due to the bone loss in the furcation. There is probably an untreated canal since microscopes were not commonplace 12 yrs ago. It 50:50 if the patient wants to keep the tooth they may get another 2-3years out of it. Good Luck!

Agree again with CRS , removal the only option possibly a bucco-lingual root fracture as well ( you will see on extraction ) . After extraction ensure that you currette the site well , and laser or even CHX to help avoid future issues . Peter

Thanks Peter and CRS, both are great comments! At the same time I posted this case, I had also posted the previous #19 case: A non-endodontically treated case with a very large cyst. Apparently, due to the numerous postings for that initial case, 56 comments at my last count, this second #19 case (this time with endo treatment) was slow to appear. Since then, my local endodontist suggested that this current RCT treated case is a definite extraction/graft/implant case. He then noted that the other #19 fistula case, with no previous RCT treatment, could be endodontically treated if my patient accepted a guarded prognosis. Meanwhile, those doctors that suggested that my previously posted #19 “non-endo treated” tooth with an extremely large periapical lesion be extracted/biopsy/bone grafted, might have been prescience to a future dentist’s decision tree process. Earlier this week, the head of a university implant program told me that if not for the current (“turfing”) politics of his dental school and the ensuing “blow back” he would get for his forward looking opinions, he would suggest to his students that the non-endodontically treated tooth #19 of my previous post be removed/bone grafted and an implant placed. He felt, for his own mouth, the long-term excellent success rate of his implants, in a situation with good bone support etc., far outweighed having a guarded endo prognosis. This again begs the question: “Do we watch and wait with PA films to see if or when an asymptomatic, endo treated tooth with a chronic cystic lesion breaks through the critical buccal plate and/or has created a long standing sinus infection, then decide that an endodontic failure occurred? Or, will we be proactive, with increasingly lower CBCT radiation, and use that knowledge to help prevent and/or monitor theses cases before they become issues with difficult and costly repairs? I keep telling my skeptical patients “an infection in the mouth is an infection in the body.” Now that we have the ability to detect these “issues” do we really have the right to ignore them because we can’t see them on a PA? It took two decades of forward decision tree progress in periodontics to fully embrace implantology, is it really necessary to wait that long in endodontics? What are your thoughts?

You must be very proud of 56 posts and really hitting a nerve (bad pun) with our endodontic colleagues. My protocol is simple, endo lasts about 10-15 years, needs to be done under a microscope to avoid missed canals, and any periapical pathology say larger than a few mm needs to be removed. If it has a unusual spread pattern thru the cancellous bone or is of a fairly large size or thick texture I send it for biopsy. Also if the infection spreads past the intra-oral vestibule into other spaces I usually remove the tooth ( source of infection ) and dependantly drain the infection. Unfortunately endodontist do not have this training in managing pathology and infections and eventually the patient ends up in my hands. Believe me I was also taught this in dental school and respect the value and training of endodontics. Even though I make my living removing teeth and grafting/placing implants I often talk patients into saving teeth with endo if it is the right clinical call. It is a matter of knowing the limits f the proposed treatment which I often get the 20:20 hindsite so I don't blame or judge. I just wish I could be as eloquent as Peter Fairbairn he says it so well! Usually when there is controversy I hope posters will take a second look and I am very grateful for the colleageal relationship I have with my endodontist who taught me many if these principles as all our practices evolve. Thanks for reading.

Hi CRS , yes after nearly ten years of speaking on these topics around the world especially when taking a diffrent approach you have be very diplomatic and understanding that there are many different approaches to the job we do daily . We are all always learning , so agreed sharing of experiences can posibly be more important than research per se. Controversy is merely different thoughts and ideas , so again possibly a beneficial aspect to encourage thought even if you strongly disagree.. All helps us go forward hoprfully. Regards Peter

Flapless exo-Immediate implant- use the existing crown to make screw retained temporary. You will get a result even a dentist would not be able to tell the difference. Coz u have the buccal crestal bone. This miracle happens only if you do flap less-immediate implant with screw retained temporary. Center for Implant Dentistry Fremont, CA

Sam Jain- yes immediate implants are powerful, reliable, easy for the patient. yes flapless techniques are great - i accomplish what used to be though of as miracles on a daily basis with flapless techniques this being said, slow down, this is a novice blog. I don't think this case is worth a re-treat. The body is running away from this tooth. There must be some kind of root fracture. The CBCT gives an excellent picture. I would recomed removal, grafting, and a staged implant in this case. It's going to leave a pretty big hole, and yes you can screw a huge implant in it, but what's the rush??? Lets teach and preach basic skills. (And if this were my mouth, I wouldn't want the existing crown being retrofitted to the immediate implant anyway. I've done this, and it's just yucky. )

Root fractures are associated with pockets. These pockets are deep and narrow and the tactile sensation you get when you probe them is different from a typical perio pocket. Usually the periodontal lesion caused by the fracture of a mesial root is visible on the xray on the mesial side of the root, and not in the furcation. Definetly this looks like an endo lesion. The presence of al filling to the apex is not guarantee of endodontic success. If it was my tooth, I would choose the conservative option, that means the endo treatment. The outcome would be uncertain, but the reward in case of success is interesting: you keep the tooth and fill that big lesion at the same time (a graft without grafting). To sb oms: you said that dental implants are reliable. Will you define the world "reliable", please? I am not so happy about my implants sometimes. They usually perform worse than natural teeth.

The decision is not ours. I would inform the patient, thoroughly and let them decide. If they wanted my opinion, I would remove the tooth before the buccal wall is destroyed. Is that your final implant edit? B Vinci

My bad.. The edit looks fine. Bvinci

Agreed Paolo I work with an in-house endodontist and re-assess every case referred in for an Implant as to possibilty of saving . But the the saying of good money after bad may apply not due the mesial root ( the one that normally splits ) but the distal root where the lamina dura is absent indicating an issue , so a gaurded prognosis ...... Probing is a critical tool in diagnosis here but we do not have that imformation so from what we can see it looks like an extraction . As to long term implications of Implants I am more suprised how well they do long term, than the contrary and yes I have many 20 year plus cases.

Hi Poalo , maybe just a new scanner as all patients get a full scan as per previous blog and this was prior to referral to his endo specialist . We just feel the prognosis ( ten year ) is poor (the issue with the distal root was possible perf ) but not enough information really. Not one of my fingers sadly.......big hands unfortunately for this job. Regards Peter

extract-graft and later implant.... better for the patient better for the dentist....just plain better

I will urge the gp colleagues to learn the skills of immediate implant placement. Why keep putting patients through multiple surgeries and obtain inferior results. There was a time when we did not have the knowledge of immediate implant technology, now we have moved on. Immediate implant is less invasive, less traumatic for patient, swift, better treatment. So learn the skills to become good at it. That's the future. And this case, why would I do it any other way, why would I do inferior quality work for the patient. If I did not enjoy my work, if I want to shirk from hard work, and if I did not care much about the out come , I would do it the easy , traditional way, putting Px through multiple surgeries and giving Px a not so stunning result. If a Px comes with a tooth, the patient gets an immediate implant, with a SRT, I would not let the god given architecture get destroyed because of my lack of knowledge. The screw retained temporary acts a air tight lid over the socket, that keeps the sockets plumped out, saves the graft under it in the socket around the implant, it acts as a tenting device, you don't have to use sutures and membrane, or periosteal release, I can write an assay on the benefits of SRT. This sincere advice comes from your humble GP colleague Who Images, who plans, who places, who restores, and helps fellow GPs with difficult cases and complications. Sam Jain, DMD Center For Inplant Dentistry

If it is not actively infected and the entire socket is grafted with the appropriate material, with a torque stable fixture, it should not matter. Bvinci

There is an excellent article by my favorite periodontist, Dennis Tarnow on immediate placment in the JOMI vol 28no3 pages 911. He states some great guidelines in respect to bone contact area in the extraction site and the implant. I have his original DVD on sinus lifts I love this guy! It is so nice not to see an implant placed in the mesial or distal root site for a cantilevered restoration with later problems that I get to treat. I would rather not see this happen in the first place. The point is that the bone quality, lack of pathology,and morphology of the extraction site predicts if immediate placement is indicated not a business model of immediate placement or patient desire. The patient will forget about how you placed an implant immediately for time saving and convenience when there is a problem in the future they will come back. I place no implant before it's time! We are doctors, not cowboys or technicians remembering that keeps me out if trouble!

It is a rare event that one of the actual sockets is the appropriate place for the fixture. The proposed end result dictates the position. I discourage placing the implant immediately, if you can't put it where it belongs. New systems are making this a much easier proposition. For instance; I will probably always be a Nobel guy, but when placing the immediate posterior, Biohorizons has what I need. It really boils down to what you are comfortable doing. It is not a matter of being "cavalier". If you are consistently doing hard surgeries, then this case does not seem to be so challenging. I am not suggesting it doesn't deserve the same respect as all other cases. Bv

Dr levy The socket is curretted,cleaned, and scrubbed with metro/clinda soaked gauge balls until the you see the clean bone. And then the implant is placed through the radiolucency.. Infection abscess has never been a problem. Remember guys you gotta have a sharp trephine with which u drill in the furcation bone to make your osteotomy.. Drill deeper than you need, harvest the cyclinder of bone and the use piezo to erode the remaining cyclinder and a very predictable grip for the implant is created. You will not veer off to the m or distal socket, you will end up placing the implant in the prosthetic center. And you ONLY drill once. NEVER use implant drills. The 5mm thick trephine also helps you to gauge the prosthetic center much better than a thin implant drill. If the molar is single rooted or is floating in abscess and there is no apical bone but the socket walls are there, you clean the socket very well put cover screw on the implant outside the mouth and carry it to the socket with hex driver, put it right place and place Caso4/mfdba paste around the implant so that implant does not fall to the sides. Initial cases were done with the thought that if the putty of caso4 and mfdba would not work, we would have lost nothing except a implant and traditional bone grafting would then done. But it worked every time. We also held the implant in place by harvesting bone huggers from EOR to mechanically wedge the implant in place and that worked too but it was more surgery and the putty method works great so we are not harvesting bone from ramus for this purpose any more. Remember guys there are no soft tissue cuts, no lifting of gum from its place, no periosteal releases, flapless, you got the socket hole to do do your job.... Just like the way we don't do open heart surgeries And recently we have been fixating the immediate molar implants with the help of screw retained temporary which is flush with the gum. Instead of implant supporting the temporary, it is the other way round. Remember guys all this work is done without making any cuts in the gum, no lifting of soft tiisue from its place, no periosteal releases, flapless ..... You got the socket hole to do your job. I learned to think this way from Tarnow by watching his videos over and and over